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GOLD Pocket 2015 Feb18 PDF
GOLD Pocket 2015 Feb18 PDF
UC
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Obstructive
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Lung
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Disease
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POCKET GUIDE TO
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AND PREVENTION
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UPDATED 2015
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Global Initiative for Chronic
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Obstructive Lung Disease
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Pocket Guide to COPD Diagnosis,
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Management and Prevention,
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Updated 2015
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GOLD Board of Directors
Marc Decramer, MD, Chair Peter Frith, MD
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University of Leuven Repatriation General Hospital, Adelaide
Leuven, Belgium South Australia, Australia
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Alvar G. Agusti, MD David Halpin, MD
Universitat de Barcelona Royal Devon and Exeter Hospital
Barcelona, Spain Devon, UK
Jean Bourbeau, MD
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Paul Jones, MD
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McGill University Health Centre St George’s Hospital Medical School
Montreal, Quebec, Canada London, UK
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Jørgen Vestbo, MD, Denmark, UK, Chair Nicolas Roche, MD, France
Alvar Agusti, MD, Spain Roberto Rodriguez Roisin, MD, Spain
Antonio Anzueto, MD, USA Donald Sin, MD, Canada
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GOLD National Leaders
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Representatives from many countries serve as a network for the dissemination and
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3 INTRODUCTION
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4 KEY POINTS
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5 WHAT IS CHRONIC OBSTRUCTIVE
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PULMONARY DISEASE (COPD)?
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7 DIAGNOSIS OF COPD
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7 • Table 1: Key Indicators for Considering a
Diagnosis of COPD
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• Table 2: COPD and its Differential Diagnoses
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9 ASSESSMENT OF COPD
9 • Table 3: Classification of Severity of Airflow
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Limitation in COPD
10 • Table 4: Combined Assessment of COPD
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11 THERAPEUTIC OPTIONS
14 • Table 5: Formulations and Typical Doses of
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COPD Medications
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20 MANAGEMENT OF EXACERBATIONS
21 • Table 8: Indications for Hospital Assessment
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or Admission
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IN COPD
24 • Figure 1A: Normal Spirogram
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Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity
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and mortality throughout the world. Much has been learned about COPD
since the Global Initiative for Chronic Obstructive Lung Disease issued its first
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report, Global Strategy for the Diagnosis, Management, and Prevention of
COPD, in 2001. Treatment of COPD is now aimed at immediately relieving
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and reducing the impact of symptoms, as well as reducing the risk of future
adverse health events such as exacerbations. These dual goals emphasize
the need for clinicians to maintain a focus on both the short-term and long-
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term impact of COPD on their patients. A framework for COPD management
that matches individualized assessment of the disease to these treatment
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objectives will better meet each patient’s needs.
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Several educational tools and publications oriented around this approach to
COPD are available at http://www.goldcopd.org and can be adapted to
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15;187(4):347-65.
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• What You and Your Family Can Do About COPD. Information booklet
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This Pocket Guide has been developed from the Global Strategy for the
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KEY POINTS
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• Chronic Obstructive Pulmonary Disease (COPD), a common preventable
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and treatable disease, is characterized by persistent airflow limitation
that is usually progressive and associated with an enhanced chronic
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inflammatory response in the airways and the lung to noxious particles
or gases. Exacerbations and comorbidities contribute to the overall
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severity in individual patients.
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• Worldwide, the most commonly encountered risk factor for COPD is
tobacco smoking. In many countries, outdoor, occupational, and indoor
air pollution – the latter resulting from the burning of biomass fuels – are
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also major COPD risk factors.
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• A clinical diagnosis of COPD should be considered in any patient who
has dyspnea, chronic cough or sputum production, and a history of
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identification of comorbidities.
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• All COPD patients with breathlessness when walking at their own pace
on level ground appear to benefit from rehabilitation and maintenance
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of physical activity.
• COPD often coexists with other diseases (comorbidities) that may have
a significant impact on prognosis.
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WHAT IS CHRONIC
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OBSTRUCTIVE
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PULMONARY DISEASE (COPD)?
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Chronic Obstructive Pulmonary Disease (COPD), a common preventable and
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treatable disease, is characterized by persistent airflow limitation that is usually
progressive and associated with an enhanced chronic inflammatory response
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in the airways and the lung to noxious particles or gases. Exacerbations and
comorbidities contribute to the overall severity in individual patients.
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This definition does not use the terms chronic bronchitis and emphysema*
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and excludes asthma (reversible airflow limitation).
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• Dyspnea
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• Chronic cough
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*Chronic bronchitis, defined as the presence of cough and sputum production for at least 3
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months in each of 2 consecutive years, is not necessarily associated with airflow limitation.
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WHAT CAUSES COPD?
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Worldwide, the most commonly encountered risk factor for COPD is
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tobacco smoking. Outdoor, occupational, and indoor air pollution – the
latter resulting from the burning of biomass fuels – are other major COPD
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risk factors. Nonsmokers may also develop COPD.
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The genetic risk factor that is best documented is a severe hereditary
deficiency of alpha-1 antitrypsin. It provides a model for how other genetic
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risk factors are thought to contribute to COPD.
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COPD risk is related to the total burden of inhaled particles a person
encounters over their lifetime:
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• Tobacco smoke, including cigarette, pipe, cigar, and other
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types of tobacco smoking popular in many countries, as well as
environmental tobacco smoke (ETS)
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• Indoor air pollution from biomass fuel used for cooking and heating
in poorly vented dwellings, a risk factor that particularly affects
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In addition, any factor that affects lung growth during gestation and
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childhood (low birth weight, respiratory infections, etc.) has the potential to
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DIAGNOSIS OF COPD
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A clinical diagnosis of COPD should be considered in any patient who has
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dyspnea, chronic cough or sputum production, and a history of exposure to
risk factors for the disease (Table 1).
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Table 1. Key Indicators for Considering a Diagnosis of COPD
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present in an individual over age 40. These indicators are not diagnostic
themselves, but the presence of multiple key indicators increases the
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probability of a diagnosis of COPD. Spirometry is required to establish a
diagnosis of COPD.
airflow limitation and thus of COPD. All health care workers who care for
COPD patients should have access to spirometry. Appendix I: Spirometry
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Differential Diagnosis: A major differential diagnosis is asthma. In some
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patients with chronic asthma, a clear distinction from COPD is not possible
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using current imaging and physiological testing techniques. In these patients,
current management is similar to that of asthma. Other potential diagnoses
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are usually easier to distinguish from COPD (Table 2).
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Table 2. COPD and its Differential Diagnoses
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Diagnosis Suggestive Features
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COPD Onset in mid-life.
Symptoms slowly progressive.
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History of tobacco smoking or exposure to other types of smoke.
Asthma Onset early in life (often childhood).
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Symptoms vary widely from day to day.
Symptoms worse at night/early morning.
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Allergy, rhinitis, and/or eczema also present.
Family history of asthma.
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Microbiological confirmation.
High local prevalence of tuberculosis.
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mandatory. For example, a person who has never smoked may develop COPD
(especially in the developing world where other risk factors may be more important
than cigarette smoking); asthma may develop in adult and even in elderly patients.
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ASSESSMENT OF COPD
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The goals of COPD assessment are to determine the severity of the disease, its
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impact on patient’s health status, and the risk of future events (exacerbations,
hospital admissions, death) in order to guide therapy. Assess the following
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aspects of the disease separately:
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• Symptoms
• Degree of airflow limitation (using spirometry)
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• Risk of exacerbations
• Comorbidities
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Assess Symptoms: Validated questionnaires such as the COPD Assessment
Test (CAT) or the Clinical COPD Questionnaire (CCQ) are recommended
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for a comprehensive assessment of symptoms. The modified British Medical
Research Council (mMRC) scale provides only an assessment of breathlessness.
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Assess Comorbidities: Cardiovascular diseases, osteoporosis, depression and
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anxiety, skeletal muscle dysfunction, metabolic syndrome, and lung cancer
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among other diseases occur frequently in COPD patients. These comorbid
conditions may influence mortality and hospitalizations, and should be looked
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for routinely and treated appropriately.
Combined Assessement of COPD: Table 4 provides a rubric for combining
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these assessments to improve management of COPD.
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• Symptoms:
Less Symptoms (mMRC 0-1 or CAT < 10): patient is (A) or (C)
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More Symptoms (mMRC ≥ 2 or CAT ≥ 10): patient is (B) or (D)
• Airflow Limitation:
Low Risk (GOLD 1 or 2):
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patient is (A) or (B)
High Risk (GOLD 3 or 4): patient is (C) or (D)
• Exacerbations: LT
Low Risk: ≤ 1 per year and no hospitalization for exacerbation: patient is (A) or (B)
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≥2
(Gold Classification of Airflow Limitation)
or
(Exacrbation History)
admission
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Risk
Risk
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1 (not leading
2
to hospital
0
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Breathlessness
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Spirometric Exacerbations
Patient Characteristic CAT mMRC
Classification per year
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Low Risk
A Less Symptoms
GOLD 1-2 ≤1 < 10 0-1
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Low Risk
B More Symptoms
GOLD 1-2 ≤1 ≥ 10 ≥2
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High Risk
C GOLD 3-4 ≥2 < 10 0-1
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Less Symptoms
High Risk
D More Symptoms
GOLD 3-4 ≥2 ≥ 10 ≥2
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THERAPEUTIC OPTIONS
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Smoking cessation has the greatest capacity to influence the natural history of
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COPD. Health care providers should encourage all patients who smoke to quit.
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• Counseling delivered by physicians and other health
professionals significantly increases quit rates over self-initiated
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strategies. Even a brief (3-minute) period of counseling to
urge a smoker to quit results in smoking quit rates of 5-10%.
OR
• Nicotine replacement therapy (nicotine gum, inhaler, nasal
spray, transdermal patch, sublingual tablet, or lozenge) as
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well as pharmacotherapy with varenicline, bupropion, or
nortriptyline reliably increases long-term smoking abstinence
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rates and these treatments are significantly more effective
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than placebo.
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also important.
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of air quality and, depending on the severity of their disease, avoid vigorous
exercise outdoors or stay indoors during pollution episodes.
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Physical Activity: All COPD patients benefit from regular physical activity and
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PHARMACOLOGIC THERAPIES FOR STABLE COPD
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Pharmacologic therapy is used to reduce symptoms, reduce the frequency and
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severity of exacerbations, and improve health status and exercise tolerance.
Each treatment regimen needs to be patient-specific as the relationship between
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the severity of symptoms and the severity of airflow limitation is influenced by
other factors, such as the frequency and severity of exacerbations, the presence
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of respiratory failure, comorbidities (cardiovascular disease, osteoporosis,
etc.), and general health status. The classes of medications commonly used in
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treating COPD are shown in Table 5. The choice within each class depends on
the availability of medication and the patient’s response.
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Bronchodilators: These medications are central to symptom management in
COPD.
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• Inhaled therapy is preferred.
• The choice between beta2-agonists, anticholinergics, theophylline,
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Inhaled Corticosteroids: In COPD patients with FEV1 < 60% predicted, regular
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recommended.
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Combination Inhaled Corticosteroid/Bronchodilator Therapy: An inhaled
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corticosteroid combined with a long-acting beta2-agonist is more effective
than either individual component in improving lung function and health status
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and reducing exacerbations in patients with moderate to very severe COPD.
Combination therapy is associated with an increased risk of pneumonia.
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Addition of a long-acting beta2-agonist/inhaled glucocorticosteroid to tiotropium
appears to provide additional benefits.
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Oral Corticosteroids: Long-term treatment with oral corticosteroids is not
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recommended.
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of exacerbations and chronic bronchitis, the phosphodiesterase-4 inhibitor
roflumilast reduces exacerbations treated with oral corticosteroids. These effects
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are also seen when roflumilast is added to long-acting bronchodilators; there
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are no comparison studies with inhaled corticosteroids.
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Methylxanthines. Methylxanthines are less effective and less well tolerated than
inhaled long-acting bronchodilators and are not recommended if those drugs
are available and affordable. There is evidence for a modest bronchodilator
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Vaccines: Influenza vaccines can reduce serious illness and death in COPD
patients. Vaccines containing killed or live, inactivated viruses are recommended,
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recommended for COPD patients 65 years and older, and has been shown to
reduce community-acquired pneumonia in those under age 65 with FEV1
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Table 5. Formulations and Typical Doses of COPD Medications*
Inhaler Solution for Vials for Duration
Drug (mcg) Nebulizer Oral Injection of Action
(mg/ml) (mg) (hours)
Beta2-agonists
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Short-acting
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Fenoterol 100-200 (MDI) 1 0.05% (Syrup) 4-6
Levalbuterol 45-90 (MDI) 0.21, 0.42 6-8
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Salbutamol (albuterol) 100, 200 5 5 mg (Pill), 0.1, 0.5 4-6
(MDI & DPI) 0.024%(Syrup)
Terbutaline 400, 500 (DPI) 2.5, 5 mg (Pill) 4-6
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Long-acting
Formoterol 4.5-12 (MDI & DPI) 0.01¶ 12
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Arformoterol 0.0075 12
Indacaterol 75-300 (DPI) 24
Salmeterol 25-50 (MDI & DPI) 12
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Tulobuterol 2 mg (transdermal) 24
Anticholinergics
Short-acting
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Ipratropium bromide 20, 40 (MDI) 0.25-0.5 6-8
Oxitropium bromide 100 (MDI) 1.5 7-9
Long-acting
Aclidinium bromide 322 (DPI) LT 12
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Glycopyrronium bromide 44 (DPI) 24
Tiotropium 18 (DPI), 5 (SMI) 24
Umeclidinium 62.5 (DPI) 24
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Methylxanthines
Aminophylline 200-600 mg (Pill) 240 Variable, up
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to 24
Theophylline (SR) 100-600 mg (Pill) Variable, up
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to 24
Inhaled corticosteroids
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Systemic corticosteroids
Prednisone 5-60 mg (Pill)
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Methyl-prednisolone 4, 8, 16 mg (Pill)
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Phosphodiesterase-4 inhibitors
Roflumilast 500 mcg (Pill) 24
MDI=metered dose inhaler; DPI=dry powder inhaler; SMI=soft mist inhaler
*Not all formulations are available in all countries; in some countries, other formulations may be available.
¶Formoterol nebulized solution is based on the unit dose vial containing 20 mcg in a volume of 2.0 ml
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Mucolytic Agents: Patients with viscous sputum may benefit from mucolytics
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(e.g. carbocysteine), but overall benefits are very small.
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Antitussives: Use is not recommended.
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Vasodilators: Nitric oxide is contraindicated in stable COPD. The use of
endothelium-modulating agents for the treatment of pulmonary hypertension
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associated with COPD is not recommended.
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OTHER TREATMENTS
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programs with improvements in exercise tolerance and symptoms of dyspnea
and fatigue. Benefits can be sustained even after a single pulmonary
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rehabilitation program. The minimum length of an effective rehabilitation
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program is 6 weeks; the longer the program continues, the more effective the
results. Benefit does wane after a rehabilitation program ends, but if exercise
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training is maintained at home the patient’s health status remains above pre-
rehabilitation levels.
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• PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%, with
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• PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2
of 88%, if there is evidence of pulmonary hypertension, peripheral
edema suggesting congestive cardiac failure, or polycythemia
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does not improve quality of life. There are clear benefits of continuous positive
airway pressure (CPAP) on both survival and risk of hospital admission.
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Surgical Treatments: The advantage of lung volume reduction surgery (LVRS)
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over medical therapy is more significant among patients with upper-lobe
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predominant emphysema and low exercise capacity prior to treatment,
although LVRS is costly relative to health-care programs not including surgery.
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In appropriately selected patients with very severe COPD, lung transplantation
has been shown to improve quality of life and functional capacity.
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Palliative Care, End-of-life Care, and Hospice Care: The disease trajectory in
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COPD is usually marked by a gradual decline in health status and increasing
symptoms, punctuated by acute exacerbations that are associated with an
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increased risk of dying. Progressive respiratory failure, cardiovascular diseases,
malignancies and other diseases are the primary cause of death in patients with
COPD hospitalized for an exacerbation. Thus palliative care, end-of-life care,
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and hospice care are important components of the management of patients
with advanced COPD.
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MANAGEMENT OF STABLE COPD
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Once COPD has been diagnosed, effective management should be based
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on an individualized assessment of current symptoms and future risks:
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• Relieve symptoms
• Improve exercise tolerance REDUCE SYMPTOMS
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• Improve health status
and
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• Prevent disease progression
• Prevent and treat exacerbations REDUCE RISK
• Reduce mortality
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These goals should be reached with minimal side effects from treatment,
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a particular challenge in COPD patients because they commonly have
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comorbidities that also need to be carefully identified and treated.
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NON-PHARMACOLOGIC TREATMENT
Depending on
Patient Group Essential Recommended
Local Guidelines
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Smoking
cessation Flu vaccination
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pharmacologic vaccination
treatment)
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Smoking
cessation
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Pulmonary
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rehabilitation
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PHARMACOLOGIC TREATMENT
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A proposed model for initial pharmacological management of COPD
according to the assessment of symptoms and risk (Table 4) is shown in
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Table 7.
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Bronchodilators – Recommendations:
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• For both beta2-agonists and anticholinergics, long-acting
formulations are preferred over short-acting formulations.
OR
• The combined use of short- or long-acting beta2-agonists and
anticholinergics may be considered if symptoms are not improved
with single agents.
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• Based on efficacy and side effects, inhaled bronchodilators are
preferred over oral bronchodilators.
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• Based on evidence of relatively low efficacy and greater side
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effects, treatment with theophylline is not recommended unless
other bronchodilators are not available or unaffordable for long-
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term treatment.
for patients with severe and very severe airflow limitation and
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long-term exposure.
• The phosphodiesterase-4 inhibitor roflumilast may also be used to
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Table 7: Pharmacologic Therapy for Stable COPD*
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Patient RECOMMENDED OTHER POSSIBLE
P ALTERNATIVE CHOICE
YR Group FIRST CHOICE TREATMENTS**
I LA anticholinergic
SA anticholinergic prn or
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*Medications in each LA beta2-agonist
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Theophylline
box are mentioned in SA beta2-agonist prn
D SA beta2-agonist and
alphabetical order and SA anticholinergic
therefore not necessarily in
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order of preference. SA beta2-agonist and/or
or LA anticholinergic and SA anticholinergic
TLAE anticholinergic
B
LARbeta 2
LA beta2-agonist
**Medications in this IA-agonist Theophylline
column can be used alone
or in combination with LA anticholinergic and
L-
other options in the First
DO LA beta2-agonist
ICS + LA beta2-agonist or SA beta2-agonist and/or
and Alternative Choice or LA anticholinergic and SA anticholinergic
columns C PDE-4 Inhibitor
LA anticholinergic
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or Theophylline
Glossary: LA beta2-agonist and
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SA: short-acting PDE-4 Inhibitor
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LA: long-acting ER
ICS + LA beta2-agonist and
ICS: inhaled corticosteroid Carbocysteine
LA anticholinergic
PDE-4: phosphodiesterase-4 or
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prn: when necessary ICS + LA beta2-agonist and N-acetylcysteine
ICS + LA beta2-agonist
and/or PDE-4 inhibitor
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D or SA beta 2
P-agonist
LA anticholinergic LA anticholinergic and and/or
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LA beta2-agonist SA anticholinergic
or D
LA anticholinergic and Theophylline
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PDE-4 inhibitor E
MANAGEMENT OF
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EXACERBATIONS
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An exacerbation of COPD is defined as an acute event characterized by a
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worsening of the patient’s respiratory symptoms that is beyond normal day-
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to-day variations and leads to a change in medication.
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bacterial).
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How to Assess the Severity of an Exacerbation
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• Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa
(60 mmHg) with or without PaCO2 > 6.7 kPa, (50 mmHg) when
TA
Treatment Options
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exacerbation.
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Systemic Corticosteroids: Systemic corticosteroids shorten recovery time,
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improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce
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the risks of early relapse, treatment failure, and length of hospital stay. A
dose of 40 mg prednisone per day for 5 days is recommended.
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Antibiotics: Antibiotics should be given to patients:
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• With the following three cardinal symptoms: increased dyspnea,
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increased sputum volume, increased sputum purulence;
• With increased sputum purulence and one other cardinal symptom;
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• Who require mechanical ventilation
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appropriate fluid balance with special attention to the administration of
diuretics, anticoagulants, treatment of comorbidities, and nutritional aspects
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should be considered. At all times, health care providers should strongly
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enforce stringent measures against active cigarette smoking. Patients
hospitalized because of exacerbations of COPD are at increased risk of
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COPD in the hospital depend on local resources and the facilities of the
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local hospital.
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• Older age
• Insufficient home support
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COPD AND COMORBIDITIES
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COPD often coexists with other diseases (comorbidities) that may have a
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significant impact on prognosis. In general, the presence of comorbidities
should not alter COPD treatment and comorbidities should be treated as if
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the patient did not have COPD.
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Cardiovascular disease (including ischemic heart disease, heart failure,
atrial fibrillation, and hypertension) is a major comorbidity in COPD and
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probably both the most frequent and most important disease coexisting with
COPD. Cardioselective beta-blockers are not contraindicated in COPD.
ER
Osteoporosis, anxiety/depression, and impaired cognitive function, major
comorbidities in COPD, are often under-diagnosed and are associated with
poor health status and prognosis.
LT
TA
Lung cancer is frequently seen in patients with COPD and has been found to
NO
The presence of metabolic syndrome and manifest diabetes are more frequent
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lungs.
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increased mortality.
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APPENDIX I: SPIROMETRY
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FOR DIAGNOSIS OF AIRFLOW
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LIMITATION IN COPD
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Spirometry is required to make a clinical diagnosis of COPD and should
be available to all health care professionals who work with COPD patients.
OR
What is Spirometry?
ER
Spirometry is a simple test to measure the amount of air a
person can breathe out, and the amount of time taken to do so.
LT
A spirometer is a device used to measure how effectively, and
TA
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Figure 1A: Normal Spirogram
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Figure 1B: Spirogram Typical of Patients with Mild to Moderate COPD*
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• The lower the percentage predicted FEV1, the worse the subsequent
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prognosis.
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• FEV1 declines over time and usually faster in COPD than in healthy
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subjects. Spirometry can be used to monitor disease progression,
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but to be reliable the intervals between measurements must be at
least 12 months.
OD
What You Need to Perform Spirometry
PR
Several types of spirometers are available. Relatively large bellows or
RE
rolling-seal spirometers are usually only available in pulmonary function
laboratories. Calibration should be checked against a known volume (e.g.,
OR
from a 3-litre syringe) on a regular basis. There are several smaller hand-
held devices, often with electronic calibration systems.
ER
A hard copy of the volume-time plot is very useful to checkoptimal
performance and interpretation, and to exclude errors.
LT
TA
Most spirometers require electrical power to permit operation of the motor
and/or sensors. Some battery-operated versions are available that can
NO
It is essential to learn how your machine is calibrated and when and how
DO
to clean it.
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• Breathe in fully.
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• Force the air out of the chest as hard and fast as they can until their
GH
Exhalation must continue until no more air can be exhaled, must be at least
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Like any test, spirometry results will only be of value if the expirations are
E
performed satisfactorily and consistently. Both FVC and FEV1 should be the
UC
largest value obtained from any of 3 technically satisfactory curves and the
FVC and FEV1 values in these three curves should vary by no more than
OD
5% or 150 ml, whichever is greater. The FEV1/FVC is calculated using the
maximum FEV1 and FVC from technically acceptable (not necessarily the
PR
same) curves.
RE
Those with chest pain or frequent cough may be unable to perform a
satisfactory test and this should be noted.
OR
Where to find more detailed information on spirometry:
ER
1. GOLD: A spirometry guide for general practitioners and a teaching
slide set is available: http://www.goldcopd.org
LT
TA
2. American Thoracic Society
http://www.thoracic.org/adobe/statements/spirometry1-30.pdf
NO
http://www.brit-thoracic.org.uk/copd/consortium.html
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NOTES
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